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Editorial
Robotic abdominal wall surgery: Where is its most powerful potential?
Cirugía robótica de la pared abdominal: ¿dónde está su potencial más poderoso?
Filip Muysoms
Department of Surgery, Maria Middelares Ghent, Belgium
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Robotic assisted laparoscopic hernia repair has seen a rapid adoption in the United States&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> For many countries outside of the US access to a robotic platform is limited&#44; and preference is given for urological or colorectal cancer surgery&#46; The robotic platform has some technological advantages over conventional laparoscopic surgery&#46; These include better visualisation&#44; availability of wristed instruments and a more stable operating field&#46; The question that arises is whether these advantages allow the hernia surgeon to deliver better patient care that would justify the higher cost of the robotic platform and the instruments&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a> The large majority of the studies are retrospective&#44; and the outcomes of these individual studies are not homogeneous&#44; thus decreasing the validity of their results&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">For <span class="elsevierStyleItalic">groin hernias</span>&#44; only one randomised study has been published comparing robotic and laparoscopic repair&#44; and there was no significant clinical benefit at 30-days postoperatively&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a> We have calculated a mean excess instrumentation cost for the robotic approach of &#8364;649 in a retrospective series of 404 robotic groin hernia repairs&#44; compared with 272 laparoscopic repairs&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">5</span></a> Most studies report longer operating times for robotic groin hernia repair compared with laparoscopic repair&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">3&#44;4</span></a> The effect of the learning curve must be considered and we have demonstrated similar operating times between robotic and laparoscopic groin hernia repair following the learning curve&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a> There does not seem to be any clear clinical benefit for in uncomplicated groin hernia repair to justify the higher procedural cost&#46; We do feel that robotic groin hernia repair may provide benefits in patients with complex inguinal hernias due to the advantages of the robotic platform as described above&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a> Moreover&#44; we consider robotic groin hernia repair an important first procedure in the training of surgeons to treat abdominal wall hernias robotically and acquire skills from dissection&#44; suturing&#44; and mesh handling on the abdominal wall&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Concerning <span class="elsevierStyleItalic">ventral hernias</span>&#44; a systematic review from 2018 on robotic assisted abdominal wall surgery concluded that for ventral hernias that would normally require an open procedure&#44; a robotic assisted repair may be a good option&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a> For many years we have used mesh devices with a diameter of about 7<span class="elsevierStyleHsp" style=""></span>cm in the treatment of small to medium sized ventral hernias&#46; Severe adverse events with such intra-peritoneal mesh devices have been described and the size of the mesh often does not allow a durable repair with sufficient overlap of the mesh beyond the hernia defect&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">8&#44;9</span></a> Laparoscopic ventral hernia repair allows for placement of larger meshes and most often is performed with an intra-peritoneal mesh fixed with penetrating tacker fixation after closure of the hernia defect&#46; The only randomised trial of robotic ventral hernia repair compared laparoscopic ventral hernia repair with tack fixation with an intra-peritoneal mesh fixed robotically to the abdominal wall with running sutures&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">10</span></a> No benefits in 90 day postoperative hospital days was noted&#44; but the robotic approach took longer and was more costly&#46; Several studies have been published from centres with a large expertise in laparoscopic ventral hernias repairs to warn against an increased morbidity related to subsequent abdominal surgery because of possible dense adhesions of the viscera to the intra-peritoneal meshes&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">11&#44;12</span></a> This has led to a rationale to look for minimal invasive techniques of ventral hernia repair with a mesh augmentation in the extra-peritoneal mesh positioning rather than intra-peritoneal&#46; A technique for laparoscopic retromuscular repair of ventral hernias was described in 2013&#44; but this has technical challenges in a conventional laparoscopic setting&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">13</span></a> We have adopted the robotic platform to perform this approach using the advantages of the improved ergonomics and the facilitated suturing with the wristed instruments&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> This approach eliminates the need for penetrating fixation&#44; and for coated intra-peritoneal meshes&#46; This could lead to less postoperative pain and less cost&#46; The robotic approach may be cost effective compared to the intra-peritoneal laparoscopic ventral hernia repair when the shorter hospital stay&#44; use of less expensive mesh&#44; and elimination of laparoscopic fixation devices is considered&#46; Importantly&#44; this has the added advantage of decreasing the risk related to adhesions during subsequent abdominal surgery&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The biggest potential for improved patient outcome using the robotic platform likely lies with the patients who have <span class="elsevierStyleItalic">wide incisional hernias requiring a component separation technique</span>&#46; Compared with open component separation techniques&#44; a robotic assisted minimal invasive approach has demonstrated a remarkable decrease in hospital stay postoperatively&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">15</span></a> We have noted similar outcomes with our patients following robotic TAR procedures&#46; If the posterior component separation has been successfully performed in a minimal invasive fashion with the robotic platform&#44; the immediate postoperative recovery of these patients is improved significantly&#46; Less postoperative pain results in earlier mobilisation and the lack of postoperative ileus&#44; in earlier oral intake&#46; Most patients can be discharge after 48<span class="elsevierStyleHsp" style=""></span>h even after retromuscular repairs with large meshes of 40 by 30<span class="elsevierStyleHsp" style=""></span>cm&#46; We think this should be considered the driving incentive to adopt the robotic platform in the treatment of abdominal wall hernias&#46; We are convinced that posterior component separation&#44; which is currently predominantly performed open&#44; can be performed in a minimally invasive fashion in most patients using the robotic platform&#46; The cost savings associated with decreased hospital stay will improve the cost effectiveness of the robotic approach&#46; Robotic assisted posterior component separation with transversus abdominus release or roboTAR&#44; is a difficult procedure requiring extensive skills in using the robotic platform and knowledge of abdominal wall anatomy&#46; Using a training pathway which includes robotic assisted groin hernia repairs and robotic repair of smaller ventral hernias&#44; is a mandatory investment required prior to adopting robotic techniques for the wider and more complex abdominal wall repairs&#46; We need a prospective high quality multicentre European trial to investigate and document the benefits of robotic complex ventral hernia repair compared with open repair&#46; However&#44; enough expertise must be acquired with the robotic platform by participating abdominal wall surgeons to avoid including patients in the learning curve of the surgeon to perform roboTAR&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0025" class="elsevierStylePara elsevierViewall">Filip Muysoms reports having received research grants from Intuitive&#44; Medtronic&#44; Dynamesh and received speakers honorarium from Medtronic&#44; Bard-Davol&#44; Dynamesh&#44; Intuitive and received consultancy fees from Medtronic&#44; Intuitive&#44; CMR Surgical&#46;</p></span></span>"
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Article information
ISSN: 21735077
Original language: English
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